Volume 4, Issue 2 www.exploringhandtherapy.com June 2004

In This Issue

Featured Article...............1Splinting Tips and Tricks.4Pssst! Did you know........6Test Your Knowledge......6Test answers.................10Ergo Tips and Tricks.....10AOTA, ASHT, HTCC.....13What’s Up Doc..............14

From the Editors’ Desk:

Susan Weiss Nancy Falkenstein

Greetings as we enter the sum-mer months. Exploring HandTherapy (EHT) has been busycreating new educational cours-es for your learning enjoyment.

EHT now offers excellent AOTAprovider courses via threemethods: CD-ROM, DVD, andInternet streaming. EHT addsnew courses regularly soplease visit us at our websitewww.exploringhandtherapy.comfor up to date courses at fantas-tic prices.

In this issue we are discussingthe forever challenging flexor

tendon repair. Remember toalways consult your clinicalcoordinator or referring physi-cian before you implement anyprocedure. The material pre-sented in this newsletter are theopinions of the contributors andnot necessary that of EHT.

This newsletter is made possi-ble from our advertisers. Clickon the Ads to visit their web-sites.Studying for the certified handtherapy exam... you MUSTcheck out our 3.2 CEU AOTAapproved course. Refer topage 6 for details.

Teno Fix® Tendon Repair System

The Teno Fix® Tendon RepairSystem is a new surgical device thatcould forever change the wayorthopaedic and plastic reconstruc-tive surgeons repair severed or rup-tured digital flexor tendons.Restoring digital function after flexortendon injury is one of the greatesthand surgery challenges. The TenoFix® Tendon Repair System, intro-duced by Orlando-based OrtheonMedical, represents the first use of asurgical anchor system in soft tissuerepair. Utilizing a patented technolo-gy, a small anchoring coil/core isinserted into a damaged tendon,gathering collagen fibers as it turnsand harnessing the intrinsic strengthof the tendon.

The Teno Fix® system is designedto allow patients to begin active

motion therapy potentially morequickly after surgery. This will ulti-mately lead to an earlier return tonormal motion and greatly reducingthe need for repeat surgeriescaused by scarring and adhesions.

"Beginning active motion therapy -expansion and contraction of thetendon - as soon as possible is criti-cal to a successful repair," said Dr.Melvin Rosenwasser, DepartmentChairman at the Columbia School ofMedicine. "This new surgical systemshould allow such therapy to beginmuch sooner than ever before."The Teno Fix system is currentlyindicated for repair of severed orlacerated digital flexor tendons ofthe hand (with multiple digitsrepaired); a procedure that is per-formed approximately 145,000 timesannually in the U.S. alone.Limitations of current suturing tech-

niques, combined with the inherentdelicate nature of tendon fibers,leads to an approximately 30 per-cent rate of failure, which is definedas the need for a repeat surgery.

Hand surgeons face a delicateCatch-22…beginning aggressivetherapy too soon can lead to"creep," when sutures pull throughtendon fibers and create a gap thataffects the healing process; butimmobilizing the repair can lead toscarring and adhesions that won'tallow normal, fluid motion of the ten-don. In Figures 1 and 2, the poly-mer sutures stretch, leading torepair creep and gapping until theyreach their elastic limit at which theybreak -- yielding a rupture. The fail-ure mode of the Teno Fix® is shownin Figure 3, where the stainless steelsuture does notstretch and the

continue page 2

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anchors actually rip out tendon con-tained in the anchor. Ortheon expects the benefits of theTeno Fix® system to decrease the

occurrence of such problems as gapand rupture, and increase the suc-cess of tendon repair.Biomechanical testing of the peak

load at 2mm of gap (2mm is themaximum amount of gap betweenends of a tendon before deemed aclinical rupture) of the Teno Fix®repair was 55 Newtons compared to46 Newtons for a 4/0 Cruciate (con-trol) suture repair. Also, the energy

absorbed by therepair up to 2mm ofgap was 50%greater than thecontrol (Cruciate)repair. (1) Thestrength (normalforce) required formoderate activeflexion has beenmeasured to be 20Newtons.(2)

William J. Christy,OrtheonPresident,

Stress relaxation and static progressive stretch are proven manual therapy techniquesfor permanently restoring ROM. JAS devices simulate these techniques, allowing thepatient to receive clinic-quality care in the home setting. JAS devices feature precise,patient-controlled tension settings to ensure the maximum degree of pain-free stretch.

Evolution in Rehabilitation

THE STATICPROGRESSIVESTRETCH COMPANY™

THE JAS FAMILY OF SPS DEVICES:THE PROVEN APPROACH TO RESTORING ROM

JAS Finger90° flexion to

10° hyperextension

JAS Elbow138° flexion to

10° hyperextension

JAS PronationSupination

120° supination to 100° pronation

JAS Wrist90° extension to 90° flexion

JAS Shoulder0° to 100°

external rotation20° to 120°

abduction

PROVEN BENEFITSJAS STATIC PROGRESSIVE STRETCH VS. DYNAMIC SPLINTING

©2004 Bonutti Research, Inc. JAS: The Static Progressive Stretch Company is a trademark ofBonutti Research, Inc. All rights reserved.

Joint Active Systems, Inc.JAS@bonuttiresearch.com www.jointactivesystems.com(800) 879-0117

JAS offers a full line of SPS devicesfor upper extremity therapy:

JAS SPS TherapyManually adjustable constant positioning providesstress relaxation loading

Fulcrum positioned to prevent joint surface loading

1.5 hours daily treatment time

7-10 weeks average total treatment time

Devices work bi-directionally

Custom fabricated devices

Dynamic Splint TherapyConstant tension system provides creep based loading

Fulcrum positioned across joint, creates jointsurface loading

8-12 hours daily treatment time

12-26 weeks average total treatment time

Most models work in one direction only

Off-the-shelf devices

continued on page 3

Figure 1. Kessler Repair at2mm Gap

Figure 3. Teno Fix® RepairFailure Mode is Tendon FibersPulling Out with Anchor

Figure 2. Kessler Repair at ElasticLimit, Suture Break

3

said: "Our goal is two-fold: Ortheonwants to dramatically improve thestandard of care for patients, andreduce the overall costs and re-operation rates associated with thecurrent techniques. We believe theTeno Fix system will do both." The system is already gaining atten-tion in several worldwide markets,where Teno Fix has been availablesince May 2002. "Teno Fix® hasshown great promise in allowingpatients to return to normal functionfaster than we've seen with tradition-al suture repair," said Dr. M.W.Solomons, head of the Martin SingerHand Unit at Groote SchuurHospital's Department of OrthopedicSurgery in Cape Town, South Africa.“The increased strength of repaircombined with earlier initiation oftherapy is contributing to a muchhigher success rate."

GENERAL CONSIDERATION FOROPERATIVE AND THERAPEUTICTECHNIQUES

Multiple core suture designs havebeen described in literature. An epi-tendonous suture can also be usedat the repair site and has beenshown to increase the strength ofthe repair as well as to clean up therough edges. It is clear that thenumber of strands that cross therepair site is directly proportional tothe strength of the tendon repair. Itis believed that at least a four-strandrepair plus and epitendinous sutureis required for early ACTIVE motionprograms post-operatively.

The three generally recognized clini-cal post-operative approaches totendon management are as follows:

Immobilization: In these programsthe patient is immobilized for 3-4

weeks before beginning any passivemotion (PROM) or active motion(AROM) exercises. Often used forpatients that might be noncompliantor for children (age 10 or under).These suffer the least potential forrupture, but the most potential fordebilitating adhesions and contrac-tures.

Early Passive Mobilization: Theseprotocols involve passively mobiliz-ing the repair early (within 1 week)manually or by using traction.Patients may be allowed to activelyextend and passively flex in the con-straints of their splint. Commonlyused programs include those devel-oped by Kleinert, and Duran andHouser. The problem with these pro-grams is that passive motion is likepushing a piece of spaghetti into atube, whereas with active motionprograms (described next) thespaghetti gets pulled

continued on page 9

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** When treating an extensor pollicislongus repair in zone IV or V usinga dynamic splinting protocol, thewrist is splinted in extension with theCMCJ in neutral, the MPJ at 0, andthe IPJ at 0 degrees -- The DIPJ isactively flexed to 60 degrees to pro-duce a 5mm passive glide at theEPL.

** Digit exercise splints: Followingan MPJ arthro-plasty you canfabricate a PIPJand DIPJ block toall fingers andencourage MPJ flexion. This fingerpan splint will aid in directing theforces of flexion to the MPJ duringactive flexion.

**You can use a stockinette or tubi-

grip beneath the splint to reduceany irritation a splint may cause andit will help control perspiration.

**Preventing skin irritation for over-lapped splint segments is easy. Youcan line the inside portion of circum-ferentially designed splints withmoleskin or some type of thinpadding may reduce the potentialfor irritation at the splint/skin inter-face. The key is to overlap the lin-ing onto itself to form an extra 1” to2” soft flap on the inside of thesplint. (Jacobs & Austin)

**Demonstrate donning and doffingthe splint multiple times and ensureyour patient has 100% comprehen-sion by having them donn and doffthe splint in the clinic to avoidimproper splint application.

**Splinting Finishing Touches &Tips

+Check for mobility of uninvolvedjoints

+Smooth material borders and avoidtoo much rolling or flaring, whichmay irritate adjacent soft tissuesand web spaces or may interferewith non-involved joints.

+ You want to trim strapping materi-al to contour through the webspaces to prevent the strap bordersfrom irritating these sensitive areas.(Jacobs/Asutin)

+Check the splint for compressionof nerves, if applicable, especially atthe cubital tunnel and the sensorybranch of the radial nerve.

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1. What is a new surgicaldevice that could foreverchange the way orthopaedicand plastic reconstructive sur-geons repair severed or rup-tured digital flexor tendons?

2. Beginning aggressive ther-apy too soon can lead to whatdeformity?

3. What is the minimum repairrequirements for early ACTIVEmotion?

4. The Duran and Housertechnique of therapy is whattype of therapy regime?

5. According to this articlewhat zone is treated after 24hours of surgery rather than2-3 days after surgery?

6. According to this articlewhen is gentle resistive exer-cising started?

7. A nine year old that cutshis flexor tendons is besttreated with what program?

8. What type of suture can beused at the repair site and hasbeen shown to increase thestrength of the repair as wellas to clean up the roughedges?

9. What is an early activemotion therapy regimen thatsome surgeons use and ismentioned in this article?

10. Where can you learn upto date clinical treatment tech-niques for flexor tendons?

Test Your Knowledge - answers page 10

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Surgeons have been utilizing the Teno Fix® torepair distal avulsions (jersey finger) and Zone 1lacerations. Using the Lubbers Technique, a TenoFix® anchor is placed in the proximal segment, andthe suture is passed through the anchor and outthe center of the tendon. Using a K Wire, a hole isplaced through the distal phalanx and out the nail.The Teno Fix® suture is passed through the hole,out the nail, and through a button. The tendon isreapproximated to its insertion and the bead iscrimped on top of the button. After healing, thesurgeon pulls up on the bead, cutting the suture bythe nail, and the remaining suture retracts back intothe phalanx below the nail bed.

Pssst!! Did you Know

For mor information contact www.ortheon.com

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8

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down the tube and produces a bet-ter glide for the tendon.

Early Active Mobilization: Theseprotocols have the patient perform-ing specific active exercises(AROM) within a few days of sur-gery. These exercises must be per-formed within prescribed limits. Youmust REMEMBER if you pull yourspaghetti too hard it will BREAK!The literature is growing rapidly witha diversity of postoperativeapproaches to early active mobiliza-tion.

TENO FIX POST OPERATIVETHERAPYCurrently, many surgeons and thera-pists are seeing excellent resultsusing increased and earlier activetherapy in conjunction with the TenoFix® Tendon Repair System.

Ortheon does not promote a specificprotocol of post operative therapy,but has found many therapists grad-ually increase the active therapy oftheir regimens as they become com-fortable with the expedited results ofthe Teno Fix® repairs. Therefore, atherapist who currently uses a pas-sive (such as a modified Kleinert)protocol starts to move towards acontrolled active (such as a. modi-fied Duran Place and Hold) protocolas their confidence increases.Ortheon firmly believes there is anequal balance of surgeon, therapist,and patient when working towardsobtaining exceptional outcomes. Itis best to categorize your patient'srepairs as fragile or strong repairsthrough communication with the sur-geon in order to determine whetherto back down your therapy plans orincrease your regimen goals.

Keeping your therapy specific toeach patient is difficult and takestime, but it best ensures the resultsyou and especially the patient wantto obtain. Examples of current pit-falls are patients who at three weeksfeel that they can remove their dor-sal blocking splints and use theirhands for daily activity. It may beapproprate to cast these patients sothey can’t remove the splint.Patients showing exceptional move-ment for their time increment (i.e.excellent range of motion [ROM] atinitial weeks) may have their activemotion exercises increased too sig-nificantly. This can lead to failurebecause the tendon still needs thebiological healing time. Keep inmind, hand therapy goals shouldremain:*Protect the repair*Maintain max. CONTINUED ON PAGE 11

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Answers from questions page 6

1. TenoFix

2. Creep

3. Two strand repair with epitenonrepair

4. Early passive mobilization

5. Zone 3

6. 8-12 weeks

7. Immobilization

8. An epitendonous suture

9. The Belfast protocol

10. www.liveconferences.com

CTD’s take years to fully develop,and almost as long to subside.Once your patients experience aCTD, they will always be at riskfor further incidence. Following are some commonsuggestons to help take controlof CTD’s.

Learn more about the identifica-tion, prevention, and treatment ofCTD’s. The more you and yourpatients know, the better all willbe able to treat the condition. Allgood solutions start with knowl-edge.

"Microbreaks" from writing, key-boarding, and lab work every 30minutes are essential. Stretchingexercises a few times each hour

are much more effective than a15-minute break every 2 hours.Most people need to be remindedto take a break; timers andbreak-reminder software are veryhelpful. Longer rest periods arealso recommended (e.g., 3-dayweekends or some variation intasks).

Aerobic exercise is critical forprevention of and recovery fromCTD’s. Even short exercise ses-sions every other day are enoughto affect blood flow and help thebody cope with stress. To avoidserious chronic pain, make timefor exercise.

Stretching exercises for theupper body reduces risk and

facilitates recovery. This includesupper- and mid-back, neck,shoulder, forearm, and wriststretches.

Contrast therapy relieves symp-toms in most cases by increasingcirculation and decreasingswelling. It should be done 3-4times a day for severe pain or 1-2times daily for mild pain untilsymptoms subside. A contrast"bath" can be used for the fore-arms: Immerse forearm in warmwater (100 degrees F) for oneminute and then cold water (66degrees F) for one minute.Continue alternating tempera-tures for a total of 10 - 15 min-utes. Alternatinghot and cold continued page 12

Ergo Tips and Tricks

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ROM(per specific protocol)

*Facilitate tendon excursion*Educate the patient

A passive Kleinert therapy protocolwas used during the Teno Fix® clini-cal study for both control and testpatients. The Teno Fix® patientsreturned a zero percent rupture rate.Another therapy regimen that somesurgeons use is the Belfast protocol(an early active AROM program) ora modification thereof as presentedhere:

Post-operative Splint:Maximum Wrist Flexion (minus 30degrees) and MCP's at 50 degrees.The cast/splint extends 2 cm beyondthe fingertips to inhibit use of thehand. A radial plaster "wing" wraps

around the wristjust proximal tothe thumb to pre-vent the cast frommigrating distally.On initiation oftherapy, the post-operative dressing

is debulked to allow exercise.

Note: For zone 3 injuries, therapy isinitiated 24 hours after repair, butzone 2 repairs are allowed to restuntil 48 hours after surgery to allowpostoperative inflammation to sub-side. Early Stage (Up to 4-6 weeks):Remember: Active motion exercisesincreased too significantly can leadto failure because the tendon stillneeds the biological healing time.Every 4 hours:1) Two Reps Active Flexion (PIP 30,DIP 10)2) Two Reps Passive Flexion intoPalm3) Two Reps Active Extensionthrough Splint

The first week's goal is full passiveflexion, full active extension, and

active flexion to 30 degrees at thePIP joint and 5 to 10 degrees at theDIP joint. Active flexion is expectedto gradually increase over the fol-lowing weeks, reaching 80 to 90degrees at the PIP joint and 50 to60 degrees at the DIP joint by thefourth week. In the presence of jointstiffness, passive exercises areincreased to every 2 hours. A pencould be placed behind the proximalphalanx to block the MP in flexionfor greater IP active extension if flex-ion contractures develop.Intermediate Stage (Beginning at 4-6 weeks):

Out of splint and 4 times daily - 1) Ten Reps Active Flexion eachJoint2) Ten Reps Active Extension eachJointThe splint is discontinued at 4weeks if tendon glide is poor (notachieving expected goals as stated),at 5 weeks for most patients, or at 6weeks for patients with unusuallygood tendon gliding (full fist devel-oping within the first 2 weeks).Three weeks after splinting is dis-continued, any residual flexion con-tractures are treated with finger-based dynamic extension splints. Late Stage(Beginning at 8-12 weeks):

1) Start Gentle Resistive Exercises2) Gradually Increase ResistanceOver Next 4 WeeksThe only exercise specified for thisperiod is protected passive IP exten-sion (with the MP held in flexion) inthe presence of flexion contractures.Presumably, patients continue activeflexion and extension exercises, andthe program progresses from thispoint as it would for any tendon pro-tocol, adding light resistance first aswarranted by difficulty attaining ten-don glide, and then stepping upresistance (late stage) for strength-ening.

Again, the aforementioned protocolis one of many protocols that havebeen used for flexor tendon therapy,including Teno Fix® patients. Inconclusion, patient results comedown to compliance to whicheverhand therapy regimen is chosen andunderstanding the advantages orlimitations of each patient's tendonrepair.

Procedure Images

Make Tenotomyand Install DistalAnchor

Pass 2/0StainlessSuture

Close overDistalAnchor

Make tenoto-my and InstallProximalAnchor

Insert 22 Ga.Needle asGuide

continued page 12

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For more information about Ortheonor the Teno Fix® Tendon Repair

System, contact the company at

1-866-TENOFIX, or visit the company's Web site at:http://www.ortheon.com.

(1) Data on file at Ortheon.(2) Urbaniak AAOS Symposium 1975

For continued reading refer to “What’s Up Doc” on pages 14 and15

packs for 15 minutes each canbe applied to shoulders andelbows.

Ice therapy for 10 - 15 minutestwice during the day may helprelieve symptoms. There areseveral ice options: reusablecold therapy packs, a plastic bagfilled with three cups of waterand one cup of rubbing alcohol,or frozen peas. Ice baths arealso effective and require lesstime: Rest your forearm in waterwith ice cubes for 10 seconds;then, rest hand outside tub for 10seconds. Continue for 1 1/2 min-utes. Note: If after use, the areais pale or white, do not continue.

Vitamin and mineral supple-

ments facilitate healing of softtissue and improves function.Colloidal minerals and a stress-formula multivitamin are highlyrecommended. Supplementsshould always have a lot numberand be properly sealed in a darkglass (e.g., Twin Labs).

Massage is a clinically-provenway to ease muscle tension, topromote circulation, and to man-age pain-inducing stress. Self-massage of the forearm, hands,shoulders, upper back, neck,face, legs and feet is very effec-tive, as are regular upper-bodyand full-body massages.

Over-the-counter anti-inflamma-tory agents may help if takenregularly for a period of time.These agents lose their anti-

inflammatory properties andbecome only pain relievers iftaken occasionally. Therefore,take as directed to attain a thera-peutic blood level of medication.Acknowledge written precau-tions.

Be aware that non-work factorsthat increase CTD risk: poorphysical condition, smoking, poornutrition, personal stresses, pre-vious injuries, aging, hobbies,ADLs, and certain diseases canreduce the body's tolerance tostress.

Information from the website of Working Well Ergonomics....http://www.working-well.org

Ergo Tips and Tricks

Crimp Bead afterApproximated

Cut Suture Flushagainst Back of Bead

Close over ProximalAnchor

CompleteRunningEpitendonousStitch

Re-approxi-mate Repair

Learn from anywhere in theworld... Hand and UE CEUs

Featuring:Static Progressive Splinting

&Treatment of Flexor Tendons

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From: www.AOTA.org

Vision Statement

The contributions of occupationaltherapy to health, wellness, produc-tivity, and the quality of life are wide-ly used, understood, and valued bythe society.

AOTA Certification ProgramsThe AOTA Specialties Board(AOTASB) continues its work toidentify and develop a new BoardCertification program for occupation-al therapists and a new SpecialtyCertification for occupational thera-pists and occupational therapyassistants.

Beginning January 1, 2007, occupa-tional therapists will be credentialedat the postbaccalaureate degreelevel.

From: www.ASHT.org

Hand Therapy Awareness Week

Hand Therapy Awareness Weekbrings the benefits of the hand thera-py profession to new audiences –demonstrating the advantages of pre-ventative as well as treatment proce-dures for patients who may have beenaffected by an accident or trauma.

Hand Therapy Awareness Week is anintegrated national program spon-sored by the American Society ofHand Therapists. During the week ofJune 14-18, 2004, we encourage youto sponsor and organize events inyour community, espousing the bene-fits of the profession and the servicesyou provide. Its success, however,depends a great deal on you – yourefforts at the local level, your knowl-edge of your audience, your creativityand, most importantly, your enthusi-asm.

From: www.HTCC.org

Scope of Practice and Domains ofHand Therapy

The Scope of Practice of HandTherapy may include one or more ofthe domains described below.Domains describe major areas ofresponsibility in hand therapy. Thefirst three domains include assess-ment and treatment of hand patientsin compliance with state and federallaws; treatment is based on theresults of assessment and may beprovided on a one-to-one basis, in agroup, or by consultation. The fourthdomain describes services designedfor specific population groups. Thefinal two domains describe activitiesassociated with professional prac-tice.

Surgical and TherapeuticHand Symposium

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Question: Is the Teno Fix® moretechnically challenging than the 4or 6 strand repair technique?

MR: No, it is distinctly less diffi-cult once you learn the nuancesof the various laceration levelsand pulley management – lessbulk and less tendon touches ingeneral as well as no slack in thecore suture with better caoptationand tensioning possible.LL: The Teno Fix® was inten-tionally designed to be easy toinstall and reliable in its purpose.It’s been said that once one doesTeno Fix® repairs, they will neverwant to go back to suture basedrepairs.MQ: No, if anything it is simpler.It is also designed to be morereproducible.

Question: How do you manageto use the Teno Fix® under pulleyrepairs?

MR: That question is a wholelecture in itself and is bestanswered with pictures and dia-grams not words. In essence, ina proximal zone 2 injury the pul-leys are a no brainer becauseyou can work on either side. In adistal zone 2 you either pull outthe distal stump from below theA4 for a palmar approach or do aside tenotomy for the distalanchor by hyperflexing the DIPjoint and then crimp near theproximal anchor last. The tenora-phy site will end up under thepulley but you can inspect thejuncture by delivering the tendonrepair juncture distal to the A4pulley by fully extending the digit

as well as narrowing the A4 pul-ley slightly.

LL: The same as before [withsuture repairs] – it has beenshown by Dr. Diao at theUniversity of California SanFrancisco, that there is no signifi-cant increase in the work of flex-ion when the Teno Fix glidesunder the pulleys.MQ: Because the Teno Fixanchors can be inserted intoeach end of the tendon withoutthem being apposed, one hasmore flexibility around pulleysthan with a suture repair.

Question: Do you recommendusing Teno Fix® along with pulleyreconstruction?

MR: Sure, the pulley reconstruc-tion is independent of the tendonrepair.LL: This should not be a prob-lems as long as the pulley recon-struction is not tighter that a nor-mal pulley.MQ: Pulley reconstruction is nota contraindication. If you woulddo it with a suture repair, you cando it with a Teno Fix.

Question: Do you use Teno Fix®for all flexor tendon zones?

LL: Yes, except for the thin por-tion of the sublimus tendon.MQ: You certainly can. Its great-est advantages are in the zoneswere bulk needs to be minimizedand strength is at a premium,namely zone II and zone I. It hasworked very well for the zone Ireinsertions, better than anything

else I've done. It could certainlybe used in more proximal zonesas well.

Question: When would you feela "standard" repair would be indi-cated instead of the Teno Fix®?

MR: Suture repair should bedone whenever the tendon cal-iber is inadequate.LL: Only in the cases where theflexor tendon is too small toaccept the anchor (i.e. childrenand the small finger profundus insome women).MQ: The only time a "standard"repair would be better is if thetendon is simply too small toaccept the Teno Fix device.

Question: Do you recommend inzone 2 injuries that both tendonsare repaired using the device?

MR: Yes, if the FDS lacerationsite is proximal enough to accom-modate the anchor.LL: In the decussation area, (thesublimus chiasm) I use a TenoFix in the profundus tendon andresect one limb of the sublimus.Then, I perform a suture repair inthe “strong limb.” In Zone 3 andproximal Zone 2, a Teno Fix® ineach tendon is preferable.MQ: The Teno Fix does not fit inall FDS tendons – near theirinsertion, these tendons flattenconsiderably. If it fits, the answeris yes.

Question: Is the device recog-nized by insurance plans?

15

LL: The Teno Fix® is consid-ered an implant. Many surgerycenters and most hospitalshave contract clauses with pay-ers providing reimbursement forimplants. With proper codingimplants are usually covered. MQ: Worker’s compensation,No-Fault, and Blue Cross havepaid well.

Question: Do you offer in-serv-ices to physicians and staff tolearn how to use the device?

MR: Yes, I have been givingsurgeon tutorial around thecountry and an instructionalvideo is available.LL: Yes, this can be usuallyarranged with Ortheon Medical.MQ: Ortheon sets them up; fac-ulty surgeons speak about thescience and help train.

Question: How would you rec-ommend therapists get theirphysicians to look at the TenoFix® device?

MR: Read an article or mono-graph and see or hear surgeonsthat have successfully used thedevice.LL: Quote the science!Especially the (South Africa)FDA approved blinded studywhere 17% of 4-strand controlsruptured and 0% of Teno Fix®repairs ruptured.MQ: Ask them if they'd like theirflexor tendon repair results tobe better (in a diplomatic way).If the surgeon is totally satisfiedwith his/her results, this is may

not be for him/her.

Question: Do you have anyadditional information you wouldlike to share?

MR: Try it and you will like it.LL: The Teno Fix® is felt tohave enough strength for activemotion therapy in flexor tendonapplications. When you starthaving compliant cases, as Ihave recently, where near nor-mal range of motion is restoredat 6-7 weeks, it creates a greatdeal of excitement.

Biographies

Lawrence Lubbers, MD,Clinical Associate Professor ofOrthopedic Surgery andDirector of Hand and UpperExtremity Surgery atDepartment of Orthopedics,Ohio State University; Principalof Hand and MicrosurgeryAssociates in Columbus, OH.

Melvin Rosenwasser, MDRobert E. Carroll Professor ofOrthopedic Surgery; Chief ofHand Surgery Service atColumbia University College ofPhysicians and Surgeons;Attending Orthopedic Surgeonat the New York PresbyterianHospital; Director of HandSurgery Fellowship atDepartment of OrthopedicSurgery of Columbia University,College of Physicians andSurgeons; Named in America’sTop Doctors, (Castle Connolly

Publishing, 2001).

Edward Diao, MDAssociate Professor of Surgeryand Chief of Service, Hand,Upper Extremity, andMicrovascular Surgery atUniversity of California SanFrancisco; Medical Director atUCSF-Mt. Zion AmbulatoryOrthopedics; Chaired Panel onFlexor Tendon Surgery,American Society for Surgery ofthe Hand Annual Meeting(2000, 2001, 2002); Named inAmerica’s Top Doctors, (CastleConnolly Publishing, 2001);Consulting Editor for Journal ofthe American Academy ofOrthopedic Surgeons.

Michael Solomons, MDDirector at Groote SchuurHospital Hand Unit, Departmentof Orthopedic Surgery in CapeTown, South Africa; Consultantto Conradie Hospital,Tetraplegic Upper Limb Clinic.

Matthew Quitkin, MDAttending Orthopedic Surgeonat Manus Hand Center; RobertE. Carroll Hand Fellow; authorof Biomechanical Behavior ofthe Teno Fix® and HistologicalResponse of the Teno Fix®

Thank you TENOFIX!!We look forward to hearing lots

more from you in the nearfuture.

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